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Essay On Growing Autonomous Practice In Mental Health Medical Essay

In this essay I will provide a profile of something end user in whose health care I participated in, within my clinical positioning. The client's record and history thus far will be defined, a critical analysis of the individual's current emotional, physical and communal needs will be provided by selecting and using published therapeutic/theoretical approaches. Furthermore a demonstration of how the therapeutic/theoretical approaches picked can offer a framework or guide the medical care and attention provided in examination of needs, recognition of aims/ gaols, restorative nursing interventions and medical review. Finally the writer will explore the healing efficacy of the current specialized medical environment or service where good care is being provided, consider possible option service provision options and discuss if they may or might not exactly be more good for the average person.

The customer chosen for the intended purpose of this task is a 60-year-old gentleman of United kingdom origin. I will refer to him as Peter to keep confidentiality relative to clause 5 of the Nursing and Midwifery Council (NMC) Code of Professional Practice (2002). Peter has a brief history of depressive disorder and alcohol mistreatment. He lives by itself in a three bedroom semi detached house, having segregated from his better half 7 months before after being wedded for 28yrs. She had been battling with his alcohol mistreatment for many years and her disappointment possessed just worsened that she was beginning to be stressed out herself.

The logical for choosing Peter for this essay isn't only because of my curiosity about Despair, but because I got involved in his care from initial analysis to his release to community attention and we developed a very good working romance built on trust and self-assurance.

Personal and Family History

According to Peter, he was created in Newcastle and is also the eldest of his parent's 4 children (2 males and 2 young girls); he has lost connection with all his siblings. His parents are both deceased, mum passed on about 5 years back (she had been battling with tumors for some years, he was her main carer) and Daddy passed on when he was 15 years of age (In a vehicle accident, via work). There is absolutely no history of unhappiness in his family but alcohol abuse is widespread. Peter has been wedded double, alleging that both his wives divorced him. He has twins with the first wife but following the divorce he lost contact with them, His second better half had a child from her own first relationship and they possessed another daughter collectively who now lives in Portugal.

He left school with no GCSE's to pursue a carrier in Pickup truck driving at the age of 18 which he is doing until April 2010 when he was dismissed after his licence was suspended for per annum due to a drink and traveling incident he was involved in. He made known to the assistance that he began drinking at the age of 17 but it became an issue at the age of 30, he blamed it on the divorce from the first wife which he reported kept him with nothing.

Presenting Problem

From his DOCTOR (GP) referral notes, Peter has a prognosis of major depression, he has been under the GP's care for calendar months but his condition has deteriorated, he has been having thoughts of suicide and home harm. He was recommended 30mg/ day of Mirtazapine at the time of recommendation. The GP thought that he hasn't been compliant along with his medication; this with alcoholic beverages misuse was making his condition worse. He reviews having a minimal thoughts and opinions of himself and doubts a lot about his funds/debts. He presents with an mind-boggling and extreme experience of sadness, hopelessness, despair and misery.

His potential to meet his daily needs has been deteriorating e. g. his do it yourself care have been observed to be deteriorating for somebody who is apparently to be usually self conscious of his personal hygiene as well as the GP pointed out that he has been slimming down. This prompted the GP to refer him to our team. The responsibility of our team is to help him during his problems to prevent suicide and also to prevent unnecessary medical center admission, in accordance with the Standard 7 of the National Service Construction (NSF) for Mental Health (DoH 2002a).

Hogston (1999) summarises that it's important to use a formalised construction of assessment as it enables the nurse to determine a person holistically and form a sensible theoretical base in the medical process. He continues on to add that although individuals may present with the same characteristic of a sickness, there's a considerable diversity in which individuals are afflicted by their health problems. It is therefore important to adopt a platform that recognises the uniqueness of every individual and permit the totality with their situation to be grasped (Alabaster 2000). According to Newell et al (2000) medical models are well recorded and have been widely used as an approach to examining the needs of clients, identifying problems and formulating means of helping them to improve their wellness.

The theoretical way used to analyse Peter's current mental, physical and cultural needs is the Stress Vulnerability model. The rationale for using this model is the fact that it can help in the proposal process with your client as a method of understanding why degrees of stress should be watched (Zubin and Spring and coil 1977). Used also as an examination tool is the twelve activities of daily living predicated on the Roper, Logan and Tierney model of care, the rationale being that it provides a structure for doing physical health assessments, which is the exam or inspection of first, the person all together, their basic appearance then their mechanistic function of body parts as discussed by Jarvis (2000) and the model also offers a holistic assessment of a patient. Aggleton and Chalmers (2000) state that it is simple to comprehend and without confusing terminologies. To look for the extent to which our client was frustrated we used the Geriatric Melancholy Scale (GDS) which really is a basic screening measure for depressive disorder (Brink et al, 1982).

According to Zubin and Springtime (1977) they suggested that a vulnerability to psychosis is obtained through a hereditary predisposition or as a result of environmental factors. This vulnerability, however, is not considered to be sufficient to manifest the disorder and must be 'triggered' by environmental procedures. The environmental part can be biological (contamination, even drugs and alcohol) or subconscious (e. g. difficult living situation). The 'stress' component of the model may take many forms, including: Traumatic life events, use of drugs and alcohol and stressful living conditions.

Zubin and Spring (1977) postulated that individuals vary in the amount of vulnerability they have for psychosis and also in their potential to withstand tense events. It is a person's own conception of the stressfulness of a meeting that ultimately defines the severe nature of the strain.

Psychological needs

According to Peter and the GP's referral notes, he was diagnosed with depression this past year though he was cured before for depressive disorder, 5 years ago. Isolation and lack of position i. e. being unemployed and a bachelor after so a long time of being a difficult working spouse has been a major source of his emotional stress, also the bereavement (loss of life of mum ) and lack of support networks on which he had relied on in the past.

Personality style and the way Peter has learned to deal with his problems (by alcohol consumption and isolating himself) may have added to the worsening of his condition. Having financial troubles combined with mounting debt including Home loan repayments has been difficult, he studies that after years of paying his mortgage he can't stand the very thought of his house being repossessed with only 5 years left to complete the repayment. Peter studies that he has been enjoying a lot of alcohol which has caused the majority of his problems i. e. he lost his job, traveling licence and his wife left him because of drinking.

Physical needs

Poor physical health can result in poor mental health, according to Harris and Barraclough (1998) people with mental health problems have a higher risk of early death. The stress caused by loss of employment, isolation and loss of support has been making him misuse alcohol, he accounts using alcoholic beverages as a coping system to stop mental poison and being depressed. The reported lack of weight and possible malnutrition has been consequently of poor diet and eating habits regarding to him. However because of his deteriorating mental health and physical health, combined with alcohol misuse lives him very vulnerable to other more severe physical health problems like Anorexia, lever problems or even becoming an alcoholic. Furthermore because of his low self-confidence and insufficient routine he's not determined to get out of bed, do anything, does not have any structure to his day and lacks the skills needed to do activities of everyday living.

Social needs

Socially, from the info compiled from his background, he has a very poor degree of social functioning. He is always very withdrawn, isolates himself in his house and his degree of activity is very low. His life revolves around his house, he hardly has any friends, the individual he used to confine in still left him (his partner) and his natural daughter relocated to Portugal (she's been his main support after the divorce). All this leaves him very vulnerable to self overlook, having low self esteem and cultural isolation.

This cultural isolation is a relapse risk factor and can form an important factor in the nursing involvement (Barker 2004). He accounts being overly dependent on his wife for those household tasks including cleaning, baking, paying and organising the home hold charges, this shows his lack of household skills. He is presently unemployed since he lost his job due to the drinking & driving a car incident, this resulted in a change in his interpersonal role from being the bread success for the family to relying on welfare benefits. The ongoing stress and communal isolation associated with these family circumstances can result in depressive symptoms (Bartha et al, 1999).

As reported by Burns up et al (1999) the GDS is actually a self-reported inventory with a straightforward yes/no format which lends itself to help ease of administration by the more mature person or by an interviewer, supported by a validation review by Yesavage et at (1993) cited by Norman et al (1997) the GDS effectively detects depression in clinically in-patients in the severe setting up, or their own homes and also in the continuing care setting. Based on the GDS scoring system 0-9 is known as normal, 10-19 indicates gentle melancholy and 20-30 indicates severe despair, he obtained 22 which indicated his despair was severe.

According to Roper et al (1996) the twelve activities of daily living model state governments that 'individual activities' exist between two extremes, the dependence and self-reliance continuum, with factors such as era, childhood and disorder playing a significant role in deciding the exact location of each of the twelve activities of living. The emphasis of the model is on protection of potential problems from becoming real problems, resolving genuine problems and effective management of issues that cannot be solved. The use of a holistic way was recognized by Ewles & Simnett (2000) who mentioned that all areas of health are interrelated and interdependent. Furthermore relating to standard 3 of the Country wide Services Construction (DoH 2002) this model helps empower the client by empowering his potential to do something to get control and the will to a wholesome lifestyle.

Assessment of Needs

Physical Health needs Examination:

This evaluation was done using the actions of daily living as recognized by Roper, Logan and Tierney, as follows:


Baseline respiration count number was 16 breaths each and every minute, which is within the standard range. He does not smoke and didn't have any difficulty in breathing.

Controlling body's temperature:

His body's temperature and blood pressure were taken to be able to have a 'baseline', for the nursing team to be able to compare any go up or fall predicated on his normal range in the future.

Maintaining safe environment:

Peter is unable to maintain his own protection because he's drinking too much, according to him, his house is in a total chaos (the ground is packed with rubbish); this poses a higher risk to him.

Eating and drinking alcohol:

His dietary ingestion is limited; he rarely eats cooked foods in any way citing that he is finding it difficult to make (lack of skills). He just makes sandwiches, toast and beverages alcohol almost all of the time.


He can speak very well though currently has been isolating himself from people including neighbours because the onset of his condition.

Personal cleanliness:

His personal health has been inadequate, regarding to his records from the GP he used to be a very smart gentleman.


His bowel motion is good though much less regular, this may be attributed to his lack of eating and drinking alcohol. No problems were discovered with urination.


He is having sleeping problems, he sleeps around 4 hours throughout the day and 3 hours during the night, while remaining up the rest of the night.

Expressing sexuality;

Recently divorced, has not expressed interest by means of opposite sex, he does not have any female friends.

Working and playing:

He was sacked from his job as a driver, spends his time drinking alcohol, viewing television and hardly will any activities.


He walks without help and can travel on general population transport.


He accounts that he can't take the hurt any more and is also unhappy along with his life, he feels dying is really the only answer to his problems. He reported having suicide thoughts, but does not have the stength to do it. Cited his children and grandchildren as his protecting factors, they indicate too much to him (he didn't want them to go through any pain).

Other areas evaluated include:

The stress Vulnerability model provided a framework for the assessment of needs by looking at the factors triggering him stress and the possible vulnerabilities.

Relationships and sexual functioning

Recently divorced, can't see himself with every other person except his ex lover wife. He reports that he has lost all interest in sex. The person who was supporting him has relocated to Portugal (his daughter); this leaves him susceptible to further isolation and low self esteem.

Interests and activities

He records being thinking about going to the theatre, watching sports on Tv set or at the pub. He's not participating in any activities at the moment but wish to try and do up to he can to occupy his time and reduce stress.

Education, training and employment

He left school with no GCSE's and has a problem of writing though he is able to read well; locates it difficult to create letters. He'd like to execute a DVLA course about problems of drink & travelling which will reduce the suspension he was given to half the term. He was promised by his previous boss that they can get his job when his suspension has ended. Addititionally there is need for him to find out about medication management and the value to be concordant with medication.

Benefits and finances

Currently unemployed and having financial problems. Receives unemployment benefit but it is not enough to protect all his money. He requires help apply for other benefits.


Lives in a 3 bedroom house, due to non-payment of home loan repayments, could lose his house; this has been a major source of stress which leaves him vulnerable to self harm, homelessness and more depressed.


Risk to self applied happens to be medium/high credited to frequent suicidal thoughts but no ideas, intention or prior attempts owing to identifiable defensive factors (Daughters and grandchildren).

The following problems were recognized:

1). Disturbed sleeping routine and insomnia.

2). Peter struggles to maintain his own protection.

3). He has low degree of interaction with other people (isolation and low self-confidence).

4). Lower in spirits and expressing suicidal ideation.

5). Loss of weight and failure to meet nutritional needs.

6). Self disregard and insufficient good personal hygiene

7). Not participating in to his diet requirements and abusing liquor.


According to Zubin and Originate the Stress-Vulnerability model really helps to guide nursing attention is by figuring out stressors and problems which is helpful in the formulation of goals/goals. The three main goals of treatment according to this model are:

1). Reducing natural vulnerability

To control alcoholic beverages consumption

To control his medication effectively

2). Minimizing stress

To maintain good self-hygiene and healthy sleeping pattern

To encourage eating, having and maintenance of balanced diet.

To be able to maintain his own safety by demonstrating awareness of his surroundings, whenever possible

To build relationships welfare for benefit finances/debts

To go to a DVLA course so that his suspension system will be reduced

3). Coping with stress more effectively

To elevate the patient's spirits and personal esteem

To encourage interpersonal inclusion and sign up for Occupation Therapy

To seek supportive relationships with nurses and therapists.

To encourage positive self- talk

Therapeutic Nursing Interventions

(a) Develop a therapeutic romance with client predicated on trust, empathy and understanding.

Staff to arrange with customer, once daily home visits to help him ventilate his feelings.

Encourage conversation with other service users through referral to day centres for group activities.

(b) Encourage good sleeping routines without need for medication by causing consumer keep his own sleeping graph.

(c) Consumer to be encouraged to consume and drink all meals, and be put on a food-monitoring chart.

(d) Consumer to be motivated to truly have a clean every day and meet all hygienic needs.

(e) Consumer to be educated on the necessity to take care of medication effectively by giving specific information about the medication he's taking and the way to get the best results from them.

(f) Client to be urged to avoid / reduce alcohol abuse by referring him to Alcoholics private groups.

(g) Risk examination to be achieved on a regular basis in agreement with customer.

Review frequently,

Client to seek immediate assistance if fleeting thoughts become more serious or depression deepens.

(h) Care plan to be reviewed each week.

A nursing involvement is much more likely to be successful in an atmosphere of trust and assistance. Relating to Thomas et al (1997) the social relationship between your patient and their helper is considered the primary tool for change. The partnership is necessary, however, not the only condition for successful restorative outcome. If the patient distrusts their nurse they can be less inclined to agree to help, neither will they listen closely or experience any trust of success. Having learnt to trust the nurse your client is able to start and promote his issues with the nurse, who can then help the individual to cope with his worries.

Meeting and speaking with your client everyday (someone to one) not only helps the service user ventilate his thoughts but it is also a kind of counselling which helps your client feel worthwhile as a individual, provides a hand that conveys camaraderie and assurance, can also cause strengthening the therapeutic relationship. During the home trips, the nurse can constantly assess how the client is doing on a regular basis thereby providing an accurate profile of the patient's improvement. Being engaged in-group activities can help the service end user to socialize, share encounters and ideas about how to handle depression and will also help distract him from mental poison, boredom and lack of social arousal which tend to reinforce a feeling of isolation and despair.

To help the client reduce natural vulnerability the use of medications can help correct the chemical imbalances which lead to symptoms. Corresponding to Healy D (2002) medications are one of the most powerful tools we've for minimizing or reducing symptoms and protecting against relapses. The client is usually to be informed on effective management of medication by providing specific information about the medication he's taking and getting the best results from medication by not mixing with alcoholic beverages (interferes with the beneficial effects of medication).

Sleep is essential parts of life, to defeat his sleeping problems without using medication, Peter is usually to be encourage to stick to a specific sleeping routine, that will bed and getting up at a normal time and prevent napping for long hours throughout the day as it upsets the 'body clock'. Peter would be inspired to avoid consuming too much espresso or liquor as these will disrupt his sleeping routine. A sleep-monitoring graph is usually to be launched to him to see if Peter gets enough sleep and be able to examine how effectively the interventions are.

According to Barker H (1996) for the challenge of eating and drinking, it is important that immediate treatment should include monitoring food and fluid intake to prevent dehydration and further weight loss. By placing Peter over a food monitoring graph the nursing team can observe how much food he's eating so that if necessary supplements may need to be provided e. g. Fortisip or Complan. Peter should be prompted to eat three meals each day. He should also be weighed frequently, suggest regular to help assessing his progress. Since he reported having home skills problems, staff to send him for Occupational Remedy (OT) to be trained and develop life skills e. g. baking.

According to Roper et al (1996) apart from taking pride in the look of them, people have a cultural responsibility to ensure cleanliness of body and clothing. It is important to explain the importance of good personal health to Peter. He will be reminded and encouraged to wait to his personal hygiene i. e. have a rinse, care for his hair, fingernails or toenails, teeth and mouth area.

A risk assessment needs to be performed frequently; this is relative to standard 7 of the National Service Framework (NSF) for mental health (DOH 2002), which is aimed at preventing suicide. When browsing the client there may be need to ask him if he feels or has thoughts about harming himself so as to try and find ways to minimise the chance or prevent client from committing suicide.

Clinical Review

The clinical overview of Peter's care and attention was done by evaluating of all the interventions used to facilitate recovery. Analysis is making judgements as to whether the good care activities that you carried out have successfully settled the patient's problems or satisfied his needs. An assessment meeting was held by the multidisciplinary team (MDT) once every week and the care and attention plan reviewed. Within the few weeks within my placement there were only trivial changes to his care plan but a lot of changes to Peter's display were observed.

Initially we visited him once daily but as he became better at coping with stress we changed the sessions to once every other day, with a phone call to him on alternative days. Peter experienced many social challenges, but after a couple weeks he had made friends and developed other interests like visiting the gym, food preparation, bowling and the game of golf. His medication was altered to Fluoxetine which helped him sleep better, increased his feelings, also a noticeable improvement in personal health was seen and his biological vulnerability was reduced. There was also a noticable difference in his weight credited to better eating habits.

Attending Alcoholics private helped him change his coping style; he observed the effects of liquor and what it had done to others which were a whole lot worse than his situation. By concluding other benefits forms and the conclusion of the DVLA course (which helped decrease the term for his suspension from driving a car), helped ease his financial concerns and resulted in reduced stress. The Resident Advice bureau helped him with his mortgage issue; he was able to arrange obligations using his pension efforts.

Therapeutic Efficiency of current clinical environment

Treating Peter as of this own home offered a far more personalised procedure by including him into his own community alternatively than fitted him in to the service system. In addition, it impacted on the stigma associated with hospitalisation through emphasis on community integration, including life satisfaction, internet sites looked after provided care in the least restrictive environment, without disrupting his life and providing flexibility in his daily routines. There was also an component of comfort, security, leisure, self-confidence all which is associated with being treated at home regarding to Reynolds & Hoult (1984).

On the other hands Reynolds & Hoult (1984) decided that hospitalisation is a negative, upsetting and unhelpful experience because of the rules, constraints, patient mix and insufficient communication which applied. Other themes are well known such as deprivation of liberty, insufficient autonomy, lack of status and acknowledgement, an emphasis on behavioural conformity, oppression, medicalisation of communal disharmony and removal from family. However if treatment at home does not produce good results, (e. g. the chance to client increases) hospitalisation may be considered, they have some known benefits which include 24 hour professional health care i. e. having trained carers within arm's period all the changing times and being discovered regularly really helps to minimise risk of self injury.


By evaluating the client's backdrop and history as of yet, the use of the Stress Vulnerability model and Activities of everyday living model helped in making a holistic and individualised assessment as recognized by Pearson et al (1996) of Peter's emotional, physical and sociable needs. Furthermore a demonstration of the way the therapeutic approaches used guided the nursing care and attention provided when the assessment of needs, identification of aims/ goals, restorative nursing interventions and scientific review was done.

Though the stress-vulnerability model helped to recognize stressors and problems, attention was made far better by incorporating the actions of daily living model which seen the individual as to be able to function dependently or separately. However the activities of daily living model was criticised by Salvage and Kershaw (1986) to be excellent for physical aspects of care, but interpersonal or educational aspects do not appear to be very important. Alternatively, Pearson et al (1996) liked the model for its clarity and being research based.

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